Is public health the most at risk from reform?

A virtual debate held during the government’s listening exercise on the proposed NHS reforms has concluded that the current proposed NHS reforms will put key public health campaigns, such as smoking cessation and flu prevention, at risk. 

The event, hosted by Doctors.net.uk, raised serious concerns about the bid to make local authorities and GP consortia responsible for public health initiatives when they are not trained in this area.

The concerns were aired by an expert panel comprising Dr Clare Gerada, chair Royal College of General Practitioners; Professor Lindsey Davies, president of the UK Faculty of Public Health and Sir Richard Thompson, president of the Royal College of Physicians.

Professor Davies highlighted the importance of the public health system in terms of improving the nation’s health, protecting people from infectious diseases and other health hazards, and ensuring that health services were available when needed.

Sir Richard said: “Public health is the only thing that will eventually save the NHS. At the moment, we face an increasing tide of problems, such as alcohol abuse and obesity. If these are not improved in the long term, the NHS will run out of money”.

Dr Gerada concurred: “It should be a public health-led NHS because most of the things we see in the consulting room are related to public health. Unless we address public health – we are going nowhere.”

Professor Davies said a really strong, qualified, director of health was needed within local authorities. “This person should sit at the main corporate management table and influence across the whole local authority and the health community, supported by a specialist team.”

Stressing the importance of integrated services, which meet local health needs, Professor Davies added: “What the government proposes is GP consortia planning and commissioning for their patients. The consortia could be of any size and scale, and you could have a lot of them for one local authority.

“Someone needs to bring them together. This is where the Health and Wellbeing Board would come in to look at all commissioning services, including health and social care, and put together a plan. But the board needs to have teeth and power to require people to work accordingly and sign up to the plans.”

In answer to a question about whether GP consortia could be trusted to commission public health, Professor Davies said: “GPs can be trusted to do their very best. But some GPs know more about public health than others and are much better able to do it.

“Some will need more help, at least at the beginning. I hope there will be public health expertise available to support them in doing it.”

Speaking about the way in which she believed consortia should develop, Dr Gerada said: “Commissioning groups must be of a sufficient size and have sufficient capability and confidence to commission and allocate resources according to best practice and with evidence base.

“GPs should be elected for a fixed term and hospital consultants and public health should have their say. We need to get together and decide how we can make consortia work for patients. We need teams without walls, for example, when looking at end of life care; we need to get groups together to look at everything from out of hours care to ambulance services and primary care. We need to get rid of the divide.”

This view was supported by Sir Richard Thompson who stressed the importance of hospital doctors ‘sitting at the top table in the commissioning process’ and working alongside their GP colleagues to provide high quality, integrated care.

A question to the panel, asserted that non clinical challenges would represent the biggest issue – e.g. the assignment of non clinical staff to the consortia.

In answer to this, Dr Gerada said: “The bigger the organisation, the more likely you are to get competent staff. It does not mean that you lose local focus. You could have more locality based commissioning or locality providers. Our college talks about federations of practices coming together with health and other providers to look at how to integrate services locally.”

She continued: “GPs love transformational change, not transactional. If you talk to them about strategic stuff, risk analysis and financial matters, it makes their eyes glaze over.

“GPs want to be involved in planning services for their patients. That does not mean that they want lock, stock and barrel to be running the Health Service between morning and evening surgery. You’ve got to have very competent NHS managers and public health doing it alongside you.

“We are dealing with £80bn worth of funding. There has to be a relevant structure for governance and accountability, and these things must be completely transparent.”

Professor Davies said: “Even if, as we hope, consortia have the same boundaries as local authorities, there will still be some services that need to be planned that will be beyond the local authority boundary.

“If you want to really get value for money, then you need to find ways of sharing scarce skills across the country and sometimes between countries. This means there needs to be some level of organisation between consortia and national government, and that’s an issue that is really sadly missing.”

Dr Gerada said budgets must be pooled across different sectors and Sir Richard Thompson pointed out that some parts of the country would be more expensive  because, for example, they may have more elderly patients, or more social inequality. All these things have to be worked out in the local formula, he said.

Dr Gerada continued: “There must be a primary care focus. The NHS works because GPs carry the risk. They are the gatekeepers and navigators.

“There must be investment in primary care and GPs must be at the table leading commissioning.”